Predictors of Cognitive Change in Parkinson Disease: A 2-year Follow-up Study.

BACKGROUND: Mild cognitive impairment is common in Parkinson disease (PD-MCI). However, instability in this clinical diagnosis and variability in rates of progression to dementia raises questions regarding its utility for longitudinal tracking and prediction of cognitive change in PD. We examined baseline neuropsychological test and cognitive diagnosis predictors of cognitive change in PD. METHODS: Persons with PD, without dementia PD (N=138) underwent comprehensive neuropsychological assessment at baseline and were followed up to 2 years. Level II Movement Disorder Society criteria for PD-MCI and PD dementia (PDD) were applied annually. Composite global and domain cognitive z -scores were calculated based on a 10-test neuropsychological battery. RESULTS: Baseline diagnosis of PD-MCI was not associated with a change in global cognitive z -scores. Lower baseline attention and higher executive domain z -scores were associated with greater global cognitive z -score worsening regardless of cognitive diagnosis. Worse baseline domain z -scores in the attention and language domains were associated with progression to MCI or PDD, whereas higher baseline scores in all cognitive domains except executive function were associated with clinical and psychometric reversion to "normal" cognition. CONCLUSIONS: Lower scores on cognitive tests of attention were predictive of worse global cognition over 2 years of follow-up in PD, and lower baseline attention and language scores were associated with progression to MCI or PDD. However, PD-MCI diagnosis per se was not predictive of cognitive decline over 2 years. The association between higher executive domain z -scores and greater global cognitive worsening is probably a spurious result.

Medical help-seeking intentions for cognitive impairment by the patient.

Objectives: Older adults represent one of the fastest growing population groups. As the aged population increases, incidence of Alzheimer's disease (AD) and other dementias will also increase. Professionals agree that early intervention is essential for therapeutic and quality of life purposes; however, many older adults wait several months or years to seek medical help after first noticing signs of cognitive impairment. The present study sought to identify the predictors of help-seeking for cognitive impairment by an individual for him/herself after the first detection of symptoms.Method: An online survey was administered to adults (N = 250) 50 years old and older. Individuals responded about their help-seeking intentions in response to a hypothetical vignette depicting symptoms of cognitive decline derived from a similar study with caregivers conducted by Qualls and colleagues. Additional standardized measures measuring constructs such as knowledge of Alzheimer's disease were completed.Results: The present study reveals that cognitive (i.e. symptom identification and disease attribution) and affective (i.e. symptom impact and threat appraisal) factors, as well as an interaction between the two, are predictive of help-seeking intentions with excellent model fit.Conclusion: Help-seeking intentions by individuals with possible cognitive impairment are comparable to those of potential caregivers. Contrary to hypotheses, high threat appraisal positively predicted help-seeking intentions despite the expectation that threat-induced fear would lead to avoidance. Recommendations are made for future research to further investigate both patients' help-seeking intentions and actions in response to signs of cognitive impairment.Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2021.1910791 .

The Effects of Perceived Enjoyment of Activities on Cognition in Late-Life.

Objectives: The current cross-sectional study examines the relationship between both frequency and perceived enjoyment of leisure activities and cognitive scores.Methods: We collected self-reported frequency and perceived pleasure of leisure activities from 58 healthy, community-dwelling older adults and administered a battery of cognitive tests, assessing all major domains (i.e., verbal memory, executive functioning, attention, language, and visuospatial ability).Results: Perceived pleasantness or enjoyment of Socializing and Being Effective predicted higher scores on tests of attention, processing speed, and language. Frequency of activity participation in Being Effective and Doing subscales predicted lower scores on executive functioning tasks.Conclusions: The results imply that frequency and perceived enjoyment of some activities are related to cognition in later life.Clinical Implications: Although the frequency of activities is often measured and subsequently used to address mental health and cognitive concerns in late-life (e.g., Behavioral Activation), we discuss the importance for clinicians to formally assess for enjoyment of these activities as well.

Geropsychology career pipeline perceptions.

OBJECTIVE: Using the framework of Social Cognitive Career Theory, this study aimed to ascertain attitudes and perceptions of geropsychology career paths, given the present notable geriatric workforce shortage. METHODS: An online survey was developed iteratively and disseminated through various modalities (i.e., internet, email, word-of-mouth). Participants included 28 predoctoral and 76 professional geropsychologists (N = 107; age M = 39.18, SD = 12.05). The sample was largely female (72%), non-Hispanic White (89%), and has or was working towards their PhD (82%). RESULTS: Results delineate attractive and unattractive aspects of common career options (academic, clinical Veterans Affairs [VA], clinical non-VA), and assessed the hypothetical proclivity and feasibility of switching between academic and clinically focused careers. The results found gender (women vs. men) and career stages (predoctoral vs. professional) to be significant contributors to career perceptions. CONCLUSIONS: The present study advances past literature by unveiling potential avenues to ameliorate this workforce shortage within both clinical and academic fields in geropsychology.

Responsiveness to Change of the Montreal Cognitive Assessment, Mini-Mental State Examination, and SCOPA-Cog in Non-Demented Patients with Parkinson's Disease.

BACKGROUND: Clinical monitoring of patients with Parkinson's disease (PD) for cognitive decline is an important element of care. The Montreal Cognitive Assessment (MoCA) has been proposed to be a sensitive tool for assessing cognitive impairment in PD. The aim of our study was to compare the responsiveness of the MoCA to decline in cognition to the responsiveness of the Mini Mental State Examination (MMSE) and the Scales for Outcomes of Parkinson's disease-cognition (SCOPA-Cog). METHODS: PD patients without dementia were enrolled at 6 North American movement disorders centers between 2008 and 2011. Participants received annual evaluations including the MoCA, MMSE, and SCOPA-Cog followed by formal neuropsychological testing. The gold standard for change in cognition was defined as the change on the neuropsychological test scores over the annual assessments. The Reliable Change Method was used to provide an estimate of the probability that a given difference score would be obtained by chance. The sensitivity of the MoCA, MMSE, and SCOPA-Cog to change was quantified using receiver operating characteristics (ROC) curves. RESULTS: One hundred seventeen patients were included in the analysis. Participants were followed at mean intervals of 11 ± 2 months for a median of 2 (maximum 5) visits. According to the reliable change index, 56 intervals of cognitive testing showed a decline in global cognition. ROC analysis of change in MoCA, MMSE, and SCOPA-Cog global scores compared to gold standard testing found an area under the curve (AUC) of 0.55 (95% CI 0.48-0.62), 0.56 (0.48-0.63), and 0.63 (0.55-0.70) respectively. There were no significant differences in the AUCs across the tests. The sensitivity of the MoCA, MMSE, and SCOPA-Cog to change at various thresholds for decline in scores reached a maximum of 71% for a cut-off of 1 point change on the SCOPA-Cog. CONCLUSION: Using neuropsychological testing as a gold standard comparator, the performance of the MoCA, MMSE, and SCOPA-Cog for detecting decline in non-demented PD patients over a 1-year interval is poor. This has implications for clinical practice; stable scores may not be taken as reassurance of the absence of cognitive decline.

Psychometric Evaluation of the Symptoms of Dementia Screener (SDS) in a Geriatric Primary Care Population.

Objectives: The Symptoms of Dementia Screener (SDS) is an 11-item scale developed to screen for cognitive impairment. We aim to evaluate the psychometric properties of the SDS for use in primary care. Methods: We analyzed data from 192 patients: 25 not impaired, 42 with mild cognitive impairment (MCI), and 125 with dementia. Cronbach's reliability, convergent validity, and clinical utility were examined. The SDS was investigated at the item level using binary two-parameter model item response theory (IRT) techniques. Results: The SDS demonstrated good reliability (11 items; α = .74). We found negative correlations between SDS and the Mattis DRS-2 (r = -.523, p < .01). Receiver operating characteristic (ROC) curves demonstrated acceptable clinical utility for detecting MCI and dementia with sensitivities and specificities of 83% and 52% for MCI; 78.4% and 84% for dementia, and 91% and 52% for any impairment. IRT analyses revealed 10 out of 11 items were moderately to very highly related to underlying latent factors of impairment. Conclusions: The SDS demonstrates good psychometric properties and is useful for detecting cognitive impairment in primary care settings. Clinical Implications: The SDS is an effective screening tool that does not require special training for its use in primary care. A positive screen indicates a need for further cognitive testing.

Differential item functioning analysis of items on the Geriatric Depression Scale-15 based on the presence or absence of cognitive impairment.

OBJECTIVE: The Geriatric Depression Scale-15 (GDS-15) is a screener for depressive symptoms in older adults. The present study aims to investigate the differential item functioning (DIF) of the GDS-15 items to determine whether or not they are biased by the presence of cognitive impairment. METHOD: Data from 215 older patients were used to examine the GDS-15. Individuals were categorized as cognitively impaired if they scored below the 10th percentile on the Mattis Dementia Rating Scale II. To evaluate DIF, configural invariance, metric invariance, scalar invariance, residual invariance, and factor variance were evaluated. Additional analyses were conducted to know the role identified DIF items play in the screening process. RESULTS: Most levels of invariance indicated that items operated equivalently across groups (p > 0.05). However, analysis of scalar invariance indicated worse model fit (p = 0.001), such that the threshold for Item 13 differed between the groups. Freeing this threshold resulted in scalar invariance (p = 0.12). CONCLUSIONS: Because partial measurement invariance was achieved suggesting that the tool as a whole functions similarly for older adults with and without cognitive impairment, professionals can be confident that the GDS-15 screens for depression as well in individuals with cognitive impairment as those without.

IRT Analysis of the Frontal Systems Behavior Scale: Identifying the Best Items for Use with Geriatric Patients in Primary Care.

OBJECTIVE: The Frontal Systems Behavior Scale (FrSBe) (Grace & Malloy, 2001) assesses behavioral dysfunction associated with frontal-subcortical damage; it is often used to measure these indicators of executive dysfunction in older adults with possible dementia. Although prior research supports the FrSBe's clinical utility and factorial validity, little attempt has been made to examine which items are most useful for geriatric cases. The goal of the present study is to identify these items. METHOD: Data from 304 older patients referred for neuropsychological assessment were used to examine the FrSBe's three subscales: Apathy (A; 14 items), Executive Dysfunction (E; 17 items), and Disinhibition (D; 15 items). Item properties were investigated using the Graded Response Model, a two-parameter polytomous item response theory model. RESULTS: Difficulty parameters, discrimination parameters, and information curves identified 18 items that effectively discriminate (a ≥ 1.70) between levels of behavioral dysfunction and measure a range of dysfunction (bA: -1.23 - 2.22; bD: -.29 - 2.14; bE: -1.81 - 1.77). CONCLUSIONS: Most FrSBe items were effective at discriminating various levels of behavioral dysfunction, though weaker items were identified. CLINICAL IMPLICATIONS: The findings suggest the FrSBe is a useful clinical tool when working with a geriatric population, though some items provide more information than others.

Psychological and social resources relate to biomarkers of allostasis in newly admitted nursing home residents.

OBJECTIVES: This paper presents preliminary baseline data from a prospective study of nursing home adaptation that attempts to capture the complexity of residents' adaptive resources by examining psychological, social, and biological variables from a longitudinal conceptual framework. Our emphasis was on validating an index of allostasis. METHOD: In a sample of 26 long-term care patients, we measured 6 hormone and protein biomarkers to capture the concept of allostasis as an index of physiological resilience, related to other baseline resources, including frailty, hope and optimism, social support, and mental health history, collected via interview with the resident and collaterals. We also examined the performance of self-report measures reflecting psychosocial and well-being constructs, given the prevalence of cognitive impairment in nursing homes. RESULTS: Our results supported both the psychometric stability of our self-report measures, and the preliminary validity of our index of allostasis. Each biomarker was associated with at least one other resilience resource, suggesting that our choice of biomarkers was appropriate. As a group, the biomarkers showed good correspondence with the majority of other resource variables, and our standardized summation score was also associated with physical, social, and psychological resilience resources, including those reflecting physical and mental health vulnerability as well as positive resources of social support, optimism, and hope. CONCLUSION: Although these results are based on a small sample, the effect sizes were large enough to confer some confidence in the value of pursuing further research relating biomarkers of allostasis to psychological and physical resources and well-being.

Vascular risk factors, depression, and cognitive change among African American older adults.

OBJECTIVE: Vascular burden has been linked to future depression and cognitive change in predominately European American samples. This study investigated these relationships in older African Americans. METHODS: To examine the connection between vascular risk factors, depression, and cognitive change, this study utilized data from 435 older African Americans. Specifically, the study examined the link between vascular risk at baseline with depression and cognitive functioning at a 2.5-year follow-up visit. RESULTS: High baseline vascular risk was associated with increased odds of future depression while controlling for age and current depression. A series of path analyses demonstrated links between baseline vascular risk, increases in depression, and decreases in processing speed. CONCLUSIONS: These findings suggest that African Americans with greater vascular burden are at greater risk for depression and cognitive change.

Measuring mild cognitive impairment in patients with Parkinson's disease.

We examined the frequency of Parkinson disease with mild cognitive impairment (PD-MCI) and its subtypes and the accuracy of 3 cognitive scales for detecting PD-MCI using the new criteria for PD-MCI proposed by the Movement Disorders Society. Nondemented patients with Parkinson's disease completed a clinical visit with the 3 screening tests followed 1 to 3 weeks later by neuropsychological testing. Of 139 patients, 46 met Level 2 Task Force criteria for PD-MCI when impaired performance was based on comparisons with normative scores. Forty-two patients (93%) had multi-domain MCI. At the lowest cutoff levels that provided at least 80% sensitivity, specificity was 44% for the Montreal Cognitive Assessment and 33% for the Scales for Outcomes in Parkinson's Disease-Cognition. The Mini-Mental State Examination could not achieve 80% sensitivity at any cutoff score. At the highest cutoff levels that provided specificity of at least 80%, sensitivities were low (≤44%) for all tests. When decline from estimated premorbid levels was considered evidence of cognitive impairment, 110 of 139 patients were classified with PD-MCI, and 103 (94%) had multi-domain MCI. We observed dramatic differences in the proportion of patients who had PD-MCI using the new Level 2 criteria, depending on whether or not decline from premorbid level of intellectual function was considered. Recommendations for methods of operationalizing decline from premorbid levels constitute an unmet need. Among the 3 screening tests examined, none of the instruments provided good combined sensitivity and specificity for PD-MCI. Other tests recommended by the Task Force Level 1 criteria may represent better choices, and these should be the subject of future research.

Person-centered assessment of apathy and resistance to care in people living with dementia: Review of existing measures.

Introduction: The review described in this paper builds upon the Dementia Care Practice Recommendations (DCPR) published by the Alzheimer's Association in 2018 and addresses behavior change and the need for targeted outcome measures that evolve from person-centered frameworks and help evaluate interventions. Apathy and resistance to care (RTC) are two specific behavioral expressions of unmet need or distress exhibited by people living with dementia, which are upsetting to formal and family caregivers and compromise quality of life for people living with dementia. Methods: We conducted literature searches of major databases (PsycInfo, PubMed, EBSCO, CINAHL) for papers examining apathy and RTC constructs in samples of people living with dementia. Reliability and validity coefficients were reviewed and reported, along with examination of whether each measure facilitates contextual understanding of behavior. Results: Three stand-alone measures of RTC and ten measures of apathy were identified and reviewed. The RTC measures demonstrated good psychometric properties but do not include the perspective of the person living with dementia or contextual aspects of the behavior. The identified apathy measures demonstrated fair to good psychometric properties, and although there is greater consideration of context, none adequately include the perspective of the person living with dementia. Discussion: Although reliable and valid measures have been developed to measure apathy and RTC in people living with dementia, there is greater need for conceptually driven measurement of behavior context and for tools that elicit and include the perspective of the person living with dementia.

Person-centered assessment of people living with dementia: Review of existing measures.

INTRODUCTION: Person-centered care and assessment calls for measurement tools that help researchers and providers understand people with dementia, their social relationships, and their experience of the care environment. This paper reviewed available measures and evaluated their psychometric properties. METHODS: Literature searches of major databases (PsycInfo, PubMed, EBSCO, CINAHL) for papers examining person-centered constructs in samples of people living with dementia or mild cognitive impairment. Reliability and validity coefficients were reviewed and reported. RESULTS: We identified 26 unique measures that had been tested in samples of people living with dementia. Twelve measures of hope, well-being, engagement, social relationships, meaning, resilience, stigma, spiritual beliefs and practices, values and preferences, and positive psychology constructs had strong psychometric properties in samples with dementia. DISCUSSION: A variety of reliability and valid measures were identified for use in person-centered care and research with people living with dementia. Additional measure development is needed for key person-centered concepts including dignity and strengths.

Clinician Word Use in Dementia Evaluation Reports as a Function of Cognitive Impairment.

Objectives: To examine the extent to which levels of cognitive status influence patterns of word use in dementia evaluation reports. Methods: We utilized neuropsychological evaluation reports from 61 geriatric primary care patients referred for suspected dementia. Linguistic Inquiry Word Count analysis was utilized to examine clinician language use in patient reports and whether language use differs dependent on the diagnosis rendered. ANOVA analyses were used to analyze group differences in LIWC word counts across clinical indices of cognitive functioning: dementia diagnosis. Results: Our analysis revealed significant differences in language use across diagnostic categories. ANOVA analyses yielded differences in broad negative emotion, F(2,58) = 4.010, p = .023 as well as other subgroups; anxiety-related word groups, F(2,58) = 4.706, p = .013; insight words, F(2,58) = 3.815, p = .028; causation words, F(2,58) = 3.497, p = .037; certainty words, F(2,58) = 6.581, p = .003; negation words, F(2,58) = 3.165, p = .05; time-related words; F(2, 58) = 7.521, p < .001; and human-related words, F(2,58) = 6.512, p = .003. Conclusion: The differences in clinician language use across different diagnostic groups may be reflections of implicit emotional reactions. Many of the patterns found in this study can be linked to previous research concerning word use and underlying thought processes. Clinical Implications: Awareness of language use is helpful in clinical relationships to attenuate stigma and facilitate treatment and research.

Vascular risk and depression in the Hispanic Established Population for the Epidemiologic Study of the Elderly (EPESE).

OBJECTIVE: Although vascular depression has received considerable research attention, relatively little research in this area has focused on minority samples. This study investigated the association between baseline vascular risk factors (VRFs) and risk for elevated depressive symptoms at 2-year follow-up in a sample of 964 individuals without significant depressive symptomotology (CES-D < 12) or cognitive impairment (MMSE>or= 24) at baseline from the Hispanic Established Population for the Epidemiologic Study of the Elderly. METHODS: We examined the associations between self-reported baseline vascular risk factors (chest pain, heart attack, stroke, hypertension, diabetes, and smoking) and a composite of these risk factors with elevated depressive symptoms (CES-D >or= 16) at 2-year follow-up. RESULTS: Seventy-four (7.7%) of the 964 participants without evidence of depression at baseline demonstrated elevated depressive symptoms (CESD >or= 16) 2 years later. There was an overall pattern of higher rates of elevated depressive symptoms at 2-year follow-up with increasing number of vascular risk factors (0 VRFs = 6.4%, 1 VRF = 5.5%, 2 VRFs = 7.7%, and 3 or more VRFs = 14.7%). After controlling for demographic variables, physical functioning, and other medical conditions, the cumulative vascular risk index was significantly associated with elevated depressive symptoms at 2-year follow-up (p < 0.05). CONCLUSIONS: Our results suggest vascular conditions may contribute to risk for depression over time among Mexican American elders, and this is relatively independent of other medical conditions. These findings suggest that depression is an additional long-term complication of these common cardiovascular disorders.

The cognitive functioning of older adult instrumental musicians and non-musicians.

This study examined similarities and differences in the cognitive profiles of older adult instrumental musicians and non-musicians. We compared neuropsychological test scores among older adult non-musicians, low-activity musicians (<10 years of lessons), and high-activity musicians (≥10 years of lessons), controlling for self-reported physical and social activity, years of education, and overall health. Significant differences among groups were found on tasks of visual spatial ability, naming, and executive functioning. No significant differences were found on tests of attention/processing speed, or episodic memory. The current study supports late life cognitive benefits of early musical training, but only in select cognitive domains, including language, executive functioning, and visual spatial ability. The results are discussed in the context of cognitive reserve and aging.

Perspectives on depression, mild cognitive impairment, and cognitive decline.

CONTEXT: The public health implications of depression and cognitive impairment in late life are enormous. Cognitive impairment and late-life depression are associated with increased risk for subsequent dementia; however, investigations of these phenomena appear to be proceeding along separate tracks. OBJECTIVES AND DATA SOURCE: The National Institute of Mental Health organized the conference "Perspectives on Depression, Mild Cognitive Impairment, and Cognitive Decline" to consider how the varied perspectives might be better integrated to examine the associations among depression, mild cognitive impairment, and cognitive decline and to illuminate the common or distinct mechanisms involved in these associations. DATA SYNTHESIS: The following 2 broad questions were addressed: (1) What gaps in our knowledge have the greatest public health significance? (2) Can we more efficiently use our research dollars and participant resources to fill these gaps? Meeting participants included grantees from the National Institute of Mental Health and the National Institute on Aging and program staff from the National Institute of Mental Health, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke. CONCLUSIONS: One of the most important recommendations to emerge from the meeting discussions is for increased collaboration among clinical and epidemiological investigators whose work focuses in the area of depression with those working primarily in the area of memory disorders. Directions for future research were identified.

Verbal learning and everyday functioning in dementia: an application of latent variable growth curve modeling.

This study used latent variable growth curve modeling to identify predictors and correlates of verbal learning over trials on a list-learning task in patients with dementia. Data from 116 patients evaluated at the Detroit satellite of the Michigan Alzheimer's Disease Research Center were incorporated in the present analyses. Patients were administered the Fuld Object Memory Evaluation, examined independently by a geriatrician, and, if appropriate, given a diagnosis of probable Alzheimer's disease according to criteria from the National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association. The presence of dementia significantly predicted both the intercept (i.e., level of performance) and the slope (i.e., learning over trials), with dementia patients demonstrating lower overall levels of performance and less verbal learning over trials. Rate of verbal learning over trials was a significant predictor of everyday functioning (instrumental activities of daily living) above and beyond general cognitive impairment and demographics.

The effects of preexisting depression on cerebrovascular health outcomes in geriatric continuing care.

BACKGROUND: Previous studies have investigated depression as the cause and outcome of vascular deficit in elderly persons. METHODS: The authors wanted to determine whether baseline depression is predictive of subsequent cardiovascular events in very elderly persons residing in a continuing care retirement community (n = 181). RESULTS: Controlling for demographic factors, both depression and the number of cardiovascular risk factors (CVRFs) at baseline were strongly predictive of stroke, whereas only CVRFs strongly predicted myocardial infarctions. Depression accounted for 12% of the variance in stroke incidence, beyond the contribution of CVRFs. Path analysis indicated that depression was also a partial moderator of the effect of CVRFs. CONCLUSIONS: In support of the vascular depression hypothesis, the study findings indicate that, for the oldest old, depression may be a strong predictor of future stroke. The presence of depression in elderly patients should alert physicians to carefully investigate other stroke risk factors and to integrate depression into an overall intervention regimen for reducing patients' risks for stroke.

Peripheral arterial tonometry events and electroencephalographic arousals in children.

STUDY OBJECTIVES: Peripheral arterial tonometry (PAT) is a sensitive measure of moment-to-moment changes in sympathetic activity and reliably identifies arousals in adult subjects. We investigated whether PAT events during sleep are associated with visually recognizable electroencephalographic arousals in healthy children and in children with sleep-disordered breathing. DESIGN: Prospective cohort. SETTING: Pediatric Sleep Research Laboratory. PARTICIPANTS: Twenty children with obstructive sleep apnea syndrome, 20 children with mild sleep-disordered breathing, and 20 control children with a mean age of 7.6 +/- 2.6 years (range: 5.7-16.5 years); 53% of children were boys. INTERVENTIONS AND MEASUREMENTS: Polysomnographic evaluation in the sleep laboratory with concomitant recording of PAT. PAT events were defined as attenuations from immediately preceding baseline of 20% to 50% (PAT20) and > 50% (PAT50) for at least 5 seconds and the indexes calculated per hour of sleep time that included good-quality PAT signals. Total PAT index (the sum of PAT20 index and PAT50 index) was also calculated. RESULTS: Total PAT index correlated with total arousal index and spontaneous arousal index (r = 0.55, P < .0001, r = 0.64, P < .001, respectively), especially in the group with obstructive sleep apnea syndrome (r = 0.71, P < .0001). The sensitivity and specificity of PAT for identifying electroencephalographic arousals were 95% and 35%, respectively. The PAT device identified pathologic arousals indexes (> or = 16 per hour) (area under the curve 0.79, P = .002). Thirty-five percent of respiratory events (eg, obstructive apnea or hypopnea) were associated with a visual electroencephalographic arousal, compared to 92% being associated with PAT attenuation events. CONCLUSIONS: Arousals in sleeping children are associated with increased sympathetic discharge, as evidenced by attenuations in PAT signal. However, a significant proportion of PAT attenuations were not accompanied by visual electroencephalographic arousals. Thus, the importance of these autonomic arousals has yet to be explored in association with morbidities related to sleep-disordered breathing and, therefore, PAT technology cannot be recommended as an alternative tool for measuring arousals in children. Nevertheless, these data further support the contention that adult criteria for the measurement for arousals may not be adequate in children.